The ultimate house call is to the White House

For nine years, E. Connie Mariano, FACP, was in charge of keeping the President of the United States, his family, his official visitors, the Vice President and even the first pet, healthy.

The retired Rear Admiral—she was the first Filipino-American to achieve that rank—grew up in a military family, traveled often and eventually headed up the division of general internal medicine at the Naval Hospital in San Diego before being tapped to serve as White House physician in 1992.

Dr. Mariano attends to then-Presdient Bill Clinton in 1996, who had complaints of stomach illness.

In 1994, President Bill Clinton chose her to serve as his personal physician and to direct the 40-person White House Medical Unit. She left that post and retired in 2001 to embark on the next phase of her career—executive health—first at the Mayo Clinic in Scottsdale, Ariz., and now in her private, VIP concierge care practice in Scottsdale called The Center for Executive Medicine.

At the White House, Dr. Mariano took on the task of reorganizing the medical unit to create a practice that could provide 24/7 coverage both in-house and around the world.

Dr. Mariano will be describing her work as physician to the president and offering her thoughts about health and medicine as it applies to the presidential candidates at two “History of Medicine” panels during the ACP’s Internal Medicine 2008 annual meeting. Other speakers at these sessions will discuss the topics of presidential disability, the history of VIP care and foreign leaders’ illnesses and disabilities.

Q: Why did the White House Medical Unit need reorganization?

A: A lot of the changes in the White House Medical Unit have been molded by tragedy. The biggest one was in the 1960s when President John F. Kennedy was assassinated. At the time of the assassination in Dallas, one physician was with him—a Navy Admiral—but he was in the back of the motorcade. And by the time he showed up, it was too late. What that forced the military people assigned to take care of the president to do was to recognize they needed to work with Secret Service more closely.

The other major change was prompted by the assassination attempt in 1981 on President Ronald Reagan. There was a physician in the motorcade as well, but there was no plan about what hospital do we bring the president to and who will take care of him. By the time President Reagan’s physician made it to George Washington Hospital, they already had the president in the OR. There wasn’t a protocol in place.

What I was able to do was to bring in 24-hour coverage. That means that wherever the president goes, 24 hours a day, there is a medical person with him all the time.

Q: What changes did you make in order to set up this kind of coverage?

A: The medical unit now dispatches a nurse or a medic to the city in advance. They walk through every little site the president will be traveling to from the time Air Force One lands on the tarmac to the time it leaves—be it the conference center, the hotel, the restaurant—and they look at all the medical threats, the security aspects, the health risks. They are the medical aspect of Secret Service. They designate in advance the hospital that will be used if the president should become ill or injured.

Q: What’s the most difficult aspect to plan and coordinate?

A: Overseas is the biggest challenge. We bring our own airplane that has medical equipment on board. We have a medical compartment in Air Force One.

Q: How important should voters consider the health of the presidential candidates?

A: I tell people you don’t vote for them because of their health, but you should keep in the back of your mind survivability. If you vote somebody into office who has had a history of cancer, think of the probability that that may come up later. Think of the probability that their chemotherapy may have affected their mentation.

For instance, Paul Tsongas had had lymphoma before he was running for the Democratic nomination in 1992. He was a cancer survivor at the time. But his cancer returned and he died in 1997; he would have died in his first term of office.

Also, anybody who has had a stroke has an issue. The mentation aspect is so important. Are they sharp? Do they have good memory? Obviously, if they maintained a healthy lifestyle before they got into office, they don’t have hypertension, they have low cholesterol, that’s good. And the younger the better.

Q: What about age? If elected, John McCain would be the oldest man ever inaugurated.

A: Look at [the example set by Vice President Dick] Cheney. I think his life has been extended once he got into office, because he started getting 24-hour medical care from the time he got elected. He has a few feet away from him at all times a medical team who will respond to him. He has people who remind him to take his medications. I think you live longer, actually, in the White House.

But also important is to make sure you have a good No. 2 who is younger and vibrant and who is ready to take over because if natural causes don’t kill you, the bullet might. In this job, you are a target. It’s high risk. I hate to say it, but they always live in fear of assassination.

Q: Are there different medical issues raised by the chance of electing a woman president?

A: We are very much a country that looks at the president as our role model for health: The president got his flu shot, so you all should get your flu shot. If our president is a woman, will we say, “She had a mammogram, so I must get one?” And if she doesn’t get one, what kind of example is that?

Americans expect the president to get an annual exam. If that doesn't happen, they think you are hiding something. They want to know that the president doesn’t have heart disease, that he has good cholesterol and how much he weighs.

Will a woman president want everybody to know how much she weighs? Will she say if she is on Prempro? Is she having hot flashes? People will want to know if her mammogram was normal. Does she have osteoporosis? It will raise a lot of different issues.

Q: As physician to the president, how do you balance the president’s right to privacy with the public’s right to know?

A: It’s difficult sometimes. But you can’t keep secrets [regarding their health] like presidents used to. What has changed it is 24-hour television. I used to get phone calls from people all over the country saying, “I think the president has skin cancer or a tic or a tremor.” I would say, “Why do you think that?” They would say, “I saw him on television and there was this thing on his face.” You can’t do what Woodrow Wilson did, which was have a stroke and then disappear for three or four months. You are always in the view of the camera.

“There are some very good maneuvers that have been validated that can help you out as much as technology can,” he said.

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